Surgery for Finals 27/4/16

Transcription

1 Surgery for Finals LUCIE FERGUSON 27/4/16

2 Post-op complications

3 Leg ulcers ARTERIAL Toes, foot and ankle Punched out Well defined Covered with slough/necrotic tissue Small Minimal exudate Painful Ix: ABPI, US Doppler, Arterial angiography Rx: Revascularisation angio/stenting/bypass Grafting/amputation VENOUS Affects medial ankle Sloping, gradual, poorly defined Sloughy Large High amount of exudate Don t tend to be painful Ix: US Doppler Rx: Graduated compression bandaging - note Contraindicated in arterial ulceration

4 Case study 1 75M with sudden onset back pain and collapse. BP 90/56, HR 120, Sats 92%, RR 25, T 36 PMHx: HTN, IHD, Renal colic What are the differential diagnoses? Initial investigations? Initial management? Screening programme?

5 Gallstone Disease 1. Gallstone disease 2. Cholecystitis 3. Ascending cholangitis 4. Gallstone pancreatitis Murphy s sign Charcot s triad

6 Case 2 68M with 1/52 jaundice, 4kg weight loss over past 2/12 and general malaise. PMHx - T2DM, COPD, Angina. 40 pack year history, diet high in saturated fats. Meds: Metformin, Aspirin, Rampril, Seretide, Salbutamol PRN, GTN PRN Likely diagnosis? Investigations? Management?

7 Colorectal cancer Incidence Risk Factors Cancer syndromes Presentation Investigation Staging Treatment options 2 nd most common malignancy & cause of cancer death Colorectal adenomas, UC/Crohns, FHx, Obesity, Sedentary lifestyle HNPCC, FAP PR bleeding, Fe deficient anaemia, altered BH, obstruction, weight loss Colonscopy, CT colongraphy, CT CAP, Pelvic MRI (rectal tumours) Dukes A within wall, B through wall, C involves LNs, D - mets Resection, Adjuvant chemo

8 Case 3 17F with 1/7 severe central abdominal pain with associated diarrhoea and 2 episodes of vomiting. No significant PMHx DDx? McBurney s point? Ix? Management options?

9 Stomas Colostomy Ileostomy Urostomy Usually LIF Usually RIF RIF/LIF Flush to skin Spouted Spout (thin tubes in situ post op) Draining stool Watery stool Draining urine

10 Case 4 46F, BG: Crohns with previous small bowel resection, TAH for HMB. Increased abdo pain and swelling. BNO for 5 days, passing flatus. O/E: distended abdomen, generalised tenderness, tinkling bowel sounds. PR NAD. A Small bowel obstruction, central dilated bowel, haustrations present B Large bowel obstruction, peripheral dilated loops, valvulae conniventes

11 Surgical scars

12 Hernias Inguinal canal Runs between deep and superficial rings Anterior: external oblique aponeurosis Posterior: transversalis fascia Superior: internal oblique Inferior: inguinal ligament Deep ring - hole in int oblique Direct inguinal hernias Midpoint of inguinal ligament Superifical ring - hole in external oblique

13 Benign Prostatic Hypertrophy Voiding symptoms O/E DRE may feel enlarged prostate. If any irregularity felt then consider prostate ca. Ix: U&E, PSA (taken prior to DRE, PSA can be affected by urethral Trauma e.g. catheterisation/pr). If U&Es derranged then abdo US to R/O obstruction as cause of AKI. If suspicion of ca then US guided prostate Bx Rx: 5-alpha reductase inhibitor (finasteride), alpha blocker (tamsulosin).

14 Case 5 54M PC: L flank pain, radiating to groin. Pain 10/10, nausea but no vomiting. Has noticed one episode of haematuria. PMHx: Gout, HTN, Hypercholesterolaemia O/E: Tender in L flank, apyrexial. Urine dip - blood ++ Ddx: Renal stones, tumour, Pyelonephritis Ix: Bloods, CT KUB Rx: If small <5mm then may pass spontaneously. If large and in proximal ureter then Lithotripsy. If in distal ureter then removal with ureteroscopy. Staghorn calculus would require open removal.

15 Neck Lumps

16 MCQS

17 What is the most common cause of large bowel obstruction? 1. Adhesions from previous surgery 2. Constipation 3. IBD (Crohns and UC) 4. Volvulus 5. Malignancy

18 Which of the following is not involved in a Hartmans procedure? 1. End-end anastomosis 2. Defunctioning ileostomy 3. Left hemicolectomy 4. Suturing rectum closed

19 Which type of hernia is most likely to become strangulated? 1. Indirect inguinal 2. Direct inguinal 3. Femoral 4. Epigastric 5. Paraumbilical

20 What is the ASA staus of a 38M with asthma controlled with steroid inhaler presenting for elective cholecystectomy? 1. ASA1 2. ASA2 3. ASA3 4. ASA4 5. ASA5

21 Which operation is likely to result in this scar? 1. Open cholecystectomy 2. Total gastrectomy 3. Ivor Lewis Oesophagectomy 4. AAA repair 5. Liver transplant

22 Where is the majority of vitamin B12 absorbed? 1. Antral stomach 2. Proximal jejunum 3. Second part of duodenum 4. Terminal ileum 5. Caecum

23 74M with fever, LIF pain and tenderness presents with hypotension & tachycardia. What is the most likely diagnosis? 1. Ruptured appendix 2. Colorectal cancer 3. Diverticulitis 4. Ruptured AAA 5. Rectal abscess

24 Regarding fluid resuscitation in surgical patients what would be the best initial choice? 1. Gelofusin 500mls STAT 2. Hartmanns 500mls STAT % NaCl + 20mmol K 500ml STAT 4. 5% Dextrose 500mls STAT 5. 5% HAS 200mls STAT